Agency for Healthcare Research and Quality

www.ahrq.gov

Quality

Research 

for

Quality 

Health Care

Quality Research

for Quality

Health Care

A Report from AHRQ on Recent 

Activities and Future Directions

www.ahrq.gov

Department of Health and Human Services

Agency for Healthcare Research and Quality

March 2001

AHRQ Publication No. 01-0018

iii

Quality Research for Quality Health Care

Message from the Director

I am very pleased to release this report on the goals, accomplishments, and future of the

Agency for Healthcare Research and Quality. This report covers fiscal years 1999-2000. Our last

year as the Agency for Health Care Policy and Research was 1999. The Agency was reauthorized

in December 1999, a few days before its 10th anniversary and renamed as the Agency for

Healthcare Research and Quality. While we fell a few days short of that milestone, we are

celebrating the birth of a new Agency that builds on the strong foundation of high quality

research laid by its predecessors—AHCPR and the National Center for Health Services Research

and Health Care Technology Assessment. 

With our reorganization comes an increased focus on quality and patient safety and ways to

reduce medical errors. We are also emphasizing ways to accelerate and magnify the impact of

research on clinical practice and patient outcomes. 

AHCPR accomplished much during its decade. AHRQ will build on that success in the

months and years to come and continue to make a difference in the quality of health care for

Americans. 

John M. Eisenberg, M.D.

Director 

Agency for Healthcare Research and Quality

Contents

Introduction ...........................................................................................................................................1

Organizational Structure.........................................................................................................................2

National Advisory Council .....................................................................................................................3

AHRQ’s Customers ................................................................................................................................3

How AHRQ’s Research Helps People.....................................................................................................3

Organizational Chart, FY 1999 - FY 2000.............................................................................................4

Organizational Chart, FY 2001..............................................................................................................5

AHRQ’s Research Portfolio ....................................................................................................................7

AHRQ Cycle of Research .......................................................................................................................8

Opportunities for Research.....................................................................................................................9

Investigator-Initiated Research.........................................................................................................9

Targeted Research Requests ...........................................................................................................10

Nurturing Research Career Development.............................................................................................12

Partnerships and Coordination.............................................................................................................12

Strategic Plan and Goals.......................................................................................................................13

Goal 1: Support Improvements in Health Outcomes...........................................................................14

Outcomes Research Portfolio.........................................................................................................14

U.S. Preventive Services Task Force ...............................................................................................15

Put Prevention Into Practice ..........................................................................................................15

Evidence-based Practice Centers ....................................................................................................16

Centers for Education and Research on Therapeutics ...................................................................16

Translating Research into Practice..................................................................................................17

Integrated Delivery System Research Network ..............................................................................18

National Guideline Clearinghouse.................................................................................................19

Primary Care Research...................................................................................................................19

Goal 2: Strengthen Quality Measurement and Improvement ..............................................................20

CAHPS® ........................................................................................................................................20

CONQUEST ................................................................................................................................20

Research on Quality Improvement ................................................................................................21

Healthcare Cost and Utilization Project (HCUP) Quality Indicators ...........................................21

AHRQ’s Leadership in the QuIC ..................................................................................................22

Research on Patient Safety and Medical Errors..............................................................................22

Goal 3: Identify Strategies to Improve Access, Foster Appropriate Use, and Reduce 

Unnecessary Expenditures ....................................................................................................................23

Research on Priority Populations ...................................................................................................23

Medical Expenditure Panel Survey.................................................................................................26

Healthcare Cost and Utilization Project ........................................................................................27

Markets and Managed Care Research............................................................................................30

User Liaison Program.....................................................................................................................31

Future Directions..................................................................................................................................31

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Quality Research for Quality Health Care

Introduction

As we begin the 21st century, people in the

United States are living longer, healthier lives. In

1998, life expectancy at birth increased to an alltime high of 76.7 years for men and women, and

life expectancy for black males increased for the

fifth year in a row. Death rates for heart disease,

cancer, and stroke decreased. 

Heart disease continues to be the leading cause

of death for men and women of all races. The good

news is that in 1998, the age-adjusted death rate

for heart disease was about one-half of what it was

in 1970. Deaths from cancer—the second leading

cause of death—are also falling, continuing a trend

that began in 1990. Between 1970 and 1990, ageadjusted cancer death rates had steadily increased.

And finally, stroke deaths are continuing a steady

decline that began in 1992.

Despite these encouraging gains in life

expectancy and substantial progress on other health

care fronts—such as increased use of early prenatal

care and preventive services and rapid advances in

new treatment regimens for HIV and AIDS—there

are incredible challenges ahead for the U.S. health

care system. These include rising health care costs,

concerns about patient safety and medical errors,

variations in clinical practice and patient outcomes,

and barriers to care for our most vulnerable

populations.

Disparities are substantial among racial and

ethnic groups for many causes of death. Disparities

also occur between men and women and among

people with different education levels. Men and

women with less than a high school education have

death rates at least double those of people who

have education beyond high school.

Research on these and other pressing issues

forms the core mission of the Agency for

Healthcare Research and Quality. Our goal at

AHRQ is to work toward high quality, accessible,

and affordable health care for all Americans.

AHRQ conducts and supports health services

research on clinical outcomes, quality, cost, use of

resources, and access to care. Findings from

AHRQ-supported health services research are used

by clinicians, patients, health system leaders, and

others to help them make more informed health

care decisions. 

Making sure that AHRQ’s research helps to

improve the health and health care of the American

people is a touchstone for the Agency that is

evident in all aspects of our operations: from our

strategic planning process, to the consideration of

the research we fund, to our partnerships with

other groups. We work closely with our sister

agencies within the Department of Health and

Human Services, with other Federal, State, and

local agencies, and with private-sector

organizations.

AHRQ supports and conducts research that

evaluates the effectiveness, quality, and value of

health care in everyday settings, uncovering the

evidence and developing the knowledge and tools

that yield measurable improvements in quality. A

key to the success of this mission is the Agency’s

TRIP agenda, or “Translating Research Into

Practice,” which helps to ensure that the impact of

AHRQ’s research is felt by more people in a timely

manner. Through the TRIP initiative, findings

from AHRQ research are put directly to work to

improve the quality and value of health care

provided in the Nation. {Editor’s Note: See page

17 for more information about our TRIP research

agenda.}

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Quality Research for Quality Health Care

AHCPR/AHRQ in FY 1999-2000

Budget: The agency’s FY 1999 budget was

$171.055 million. AHRQ’s budget in 

FY 2000 was $203.8 million. Nearly twothirds of the budget was awarded as grants

and contracts to researchers across the

country. AHRQ’s budget for 2001 is 

$269.9 million.

Staff: 270

Director: John M. Eisenberg, M.D.

Deputy Director: Lisa Simpson, M.B., 

B.Ch., M.P.H.
This report presents information on the

programs and activities undertaken by AHRQ in

fiscal years 1999-2000 and provides some examples

of accomplishments during that time. It also

includes some of the research priorities that AHRQ

will pursue in the coming months. To set the stage

for this discussion, the report presents the

organizational structure of the Agency and key

responsibilities of its functional components,

describes the Agency’s National Advisory Council

for Health Care Policy, Research, and Evaluation,

and identifies the various audiences and customers

who use the findings from Agency-supported

research.

Organizational Structure

AHRQ has nine major components. They are:

• Center for Practice and Technology

Assessment. CPTA directs the evidence-based

practice program, consisting of: (1) the

Evidence-based Practice Centers that develop

evidence reports and technology assessments;

(2) the Internet-based National Guideline

Clearinghouse®; (3) the U.S. Preventive

Services Task Force; and (4) intramural and

extramural research and evaluation on

translating evidence-based findings into clinical

practice. CPTA also is responsible for research

on the assessment of medical technologies,

including conducting and sponsoring

technology assessments to assist decisionmaking

in other agencies. Director: Douglas B.

Kamerow, M.D., M.P.H.

• Center for Outcomes and Effectiveness

Research. COER conducts and supports

studies of the outcomes and effectiveness of

diagnostic, therapeutic, and preventive health

care services and procedures. Director: Carolyn

M. Clancy, M.D.

• Center for Primary Care Research. CPCR

conducts and supports studies of primary care

and clinical, preventive, and public health

policies and systems, including the effective

application of information technology in health

care. Director: Helen Burstin, M.D.

• Center for Organization and Delivery

Studies. CODS conducts and manages studies

of the structure, financing, organization,

behavior, and performance of the health care

system and providers within it. Director: Irene

Fraser, Ph.D.

• Center for Cost and Financing Studies.

CCFS conducts and supports studies of the cost

and financing of health care and develops data

sets to support policy and behavioral research

and analyses. Director: Steven B. Cohen,

Ph.D.

• Center for Quality Measurement and

Improvement. CQMI conducts and supports

research on the measurement and improvement

of health care quality, including surveys

regarding people’s experiences with health care

services and systems and research related to

patient safety and medical errors. Director:

Gregg Meyer, M.D., M.Sc.

• Office of Management. OM directs and

coordinates Agency-wide administrative

activities, including human resources, financial

management, information resources

management, and other support services.

Director: Willard B. Evans, Jr.

• Office of Research Review, Education, and

Policy. ORREP directs the scientific peer

review process for grants and Small Business

Innovation Research (SBIR) contracts, assigns

projects to Agency components, plans and

manages Agency health services research

training and career development programs,

develops and implements Agency policies and

procedures regarding extramural research

programs, and evaluates the scientific

contribution of proposed and ongoing research,

demonstrations, and evaluations. Director:

Francis D. Chesley, Jr., M.D.

• Office of Health Care Information. OHCI

designs, develops, implements, and manages

programs for disseminating the results of

Agency activities, including public affairs, print

and electronic publishing and dissemination,

reference services, research translation and

synthesis, and liaison activities with State and

local health policy officials. Director: Christine

G. Williams.

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3

Quality Research for Quality Health Care

On page 4 you will find a chart that shows the

agency’s organizational structure during FY 1999

and FY 2000. We are including the chart on 

page 5 to reflect our organizational structure as it is

today. The chart shows several changes to our

organization that occurred in the first few months

of FY 2001 (e.g., renaming of the Center for

Quality Measurement and Improvement as the

Center for Quality Improvement and Patient

Safety to reflect new responsibilities).

National Advisory Council for

Health Care Policy, Research, and

Evaluation

The National Advisory Council for Healthcare

Research and Quality provides advice and

recommendations to AHRQ’s Director and to the

Secretary of the Department of Health and

Human Services, on priorities for a national health

services research agenda. The 24-member panel

comprises 17 private-sector experts who contribute

a varied perspective on the health care system and

the most important questions that AHRQ’s

research should address in order to promote

improvements in the quality, outcomes, and costeffectiveness of clinical practice. The private-sector

members represent health care plans, providers,

purchasers, consumers, and researchers.

Also serving in an ex-officio capacity are

principal representatives of seven Federal agencies

that address health care issues: the National

Institutes of Health (NIH); the Department of

Defense (Health Affairs) (DoD); the Centers for

Disease Control and Prevention (CDC); the

Department of Veterans Affairs (VA); the

Substance Abuse and Mental Health Services

Administration (SAMHSA); the Food and Drug

Administration (FDA); and the Health Care

Financing Administration (HCFA).

AHRQ’s Customers

AHRQ’s customers are decisionmakers who

need objective, evidence-based, and timely

information to make informed decisions about the

health care they provide, receive, and purchase.

These customers include clinical decisionmakers,

health care system decisionmakers, policymakers,

and patients.

• Clinical Decisionmakers. The evidence

uncovered through AHRQ-sponsored research

and tools developed from those findings help

clinicians, consumers, patients, and health care

institutions make informed choices about

which treatments work, for whom, when, and

at what cost. 

• Health Care System Decisionmakers. Health

plan and health care system managers use the

findings and tools developed through

AHRQ-sponsored research to make choices on

how to improve the health care system’s ability

to increase access to care and deliver

high-quality, high-value care. Purchasers use the

products of AHRQ-sponsored research to

obtain high-quality health care services. 

• Policymakers. Public-and private-sector

policymakers use the information produced by

AHRQ to expand their ability to monitor and

evaluate the impact of system changes on

outcomes, quality, access, cost, and use of

health care and to devise policies designed to

improve the performance of the system. 

How AHRQ’s Research Helps

People

An important goal for AHRQ is that the

Agency’s research result in significant

improvements in the health of the American

people and in the delivery of health care services in

the Nation. Following are examples of some of the

ways AHRQ’s research is making a difference.

• Improved diagnosis for people with heart

attack symptoms. Three-fourths of the 

7 million Americans who come to the hospital

with symptoms of a heart attack turn out not

to have one. Nonetheless, many of these people

are admitted to the hospital because emergency

room physicians are unable to determine with

sufficient certainty that no heart attack

occurred. New results from an AHRQsponsored clinical trial show that the use of a

special imaging test on people who have a
4

www.ahrq.gov

OFFICE OF THE DIRECTOR

John M. Eisenberg, M.D.

Director

Lisa A. Simpson, M.B., B.Ch.

Deputy Director

OFFICE OF MANAGEMENT

Willard B. Evans, Jr.

Provide administrative and 

management support services

OFFICE OF RESEARCH REVIEW,

EDUCATION, AND POLICY

Francis D. Chesley, Jr., M.D.

Conduct scientific peer

review and develop research 

education opportunities

OFFICE OF HEALTH CARE 

INFORMATION

Christine Williams

Provide support to disseminate

health services research

CENTER FOR COST AND 

FINANCING STUDIES

Steven B. Cohen, Ph.D.

Acting Director

Study cost, use, and access of 

health care services

CENTER FOR ORGANIZATION

AND DELIVERY STUDIES

Irene Fraser, Ph.D.

Study organization financing, and 

performance of the health care 

system

CENTER FOR OUTCOMES AND

EFFECTIVENESS RESEARCH 

Carolyn M. Clancy, M.D.

Measure clinical outcomes of care

CENTER FOR PRIMARY

CARE RESEARCH

Helen Burstin, M.D.

Determine nature and impact 

of clinical practice

CENTER FOR PRACTICE AND

TECHNOLOGY ASSESSMENT

Douglas B. Kamerow, M.D. M.P.H.

Promote use of evidence-based 

medicine and clinical 

preventive services 

CENTER FOR QUALITY

MEASUREMENT AND 

IMPROVEMENT

Gregg M. Meyer, M.D. M.Sc.

Develop and test health care quality 

measures and improvement strategies

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

in FY 1999 and FY 2000

Department of Health And Human Services
5

Quality Research for Quality Health Care

OFFICE OF THE DIRECTOR

John M. Eisenberg, M.D.

Director

Lisa A. Simpson, M.B., B.Ch.

Deputy Director

OFFICE OF MANAGEMENT

Willard B. Evans, Jr.

Provide administrative and 

management support services

OFFICE OF RESEARCH REVIEW,

EDUCATION, AND POLICY

Francis D. Chesley, Jr., M.D.

Conduct scientific peer

review and develop research 

education opportunities

OFFICE OF HEALTH CARE 

INFORMATION

Christine Williams, M.Ed.

Provide support to disseminate

health services research

CENTER FOR COST AND 

FINANCING STUDIES

Steven B. Cohen, Ph.D.

Study cost, use, and access

of health care services

CENTER FOR ORGANIZATION

AND DELIVERY STUDIES

Irene Fraser, Ph.D.

Study organization, financing, and 

performance of the health care

system

CENTER FOR OUTCOMES AND

EFFECTIVENESS RESEARCH 

Carolyn M. Clancy, M.D.

Measure clinical outcomes

of care

CENTER FOR PRIMARY

CARE RESEARCH

Helen Burstin, M.D.

Determine nature and impact

of clinical practice

CENTER FOR PRACTICE AND

TECHNOLOGY ASSESSMENT

Douglas B. Kamerow, M.D. M.P.H.

Promote use of evidence-based 

medicine and clinical 

preventive services 

CENTER FOR QUALITY

IMPROVEMENT AND PATIENT

SAFETY

Gregg M. Meyer, M.D. M.Sc.

Develop and test health care

quality measures and

improvement strategies

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

as of JANUARY 2001

Department of Health And Human Services
normal EKG reading and symptoms consistent

with a heart attack can reduce by up to 

20 percent the number of such people who

must spend time in the hospital unnecessarily.

If the data from this trial were applied

nationally, savings from unnecessary

admissions could be $85 million per year.

• Improved screening for pregnant women.

AHRQ-funded research demonstrating the

cost-effectiveness of screening for group B

streptococcal bacteria infection in pregnant

women—a condition associated with illness

and death in newborn infants—was the basis

for CDC recommendations on screening and

treatment for this disease. The CDC

recommendations have had a major impact on

maternal and infant health. Recent research

shows that the incidence of early-onset strep

infection in infants has decreased by 65 percent

since implementation of the recommendations.

In addition, the excess incidence of disease in

black infants compared with whites decreased

by 75 percent, and the incidence of invasive

group B strep infections in pregnant women

decreased by 21 percent. 

• Improved quality in Federal health

programs. AHRQ research supports health care

quality improvement and efficiency efforts in

every Federal health agency, either directly or

indirectly. For example:

The Department’s QuIC (Quality Interagency

Coordination) Task Force is a working group of

representatives of Federal agencies with

responsibility for health care programs.

Through the QuIC, AHRQ research on the

outcomes and effectiveness of diabetes care is

contributing to quality improvement

government wide. As one of its initiatives,

QuIC member agencies are using a uniform set

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www.ahrq.gov

AHRQ Research Findings at Work

In clinical practice:

• A new add-on to a standard electrocardiograph, originally developed with funding from AHRQ,

helps hospitals reduce inappropriate admissions to cardiac care units while maintaining the quality

of care for patients. This tool helps emergency room doctors decide on hospitalization or discharge

and treatment options.

In health care systems:

• CAHPS® is a survey-based tool to evaluate people’s experiences with their health plans. It was

developed by AHRQ to provide purchasers and others with information they can use to judge health

care quality. Members of the Central Florida Health Care Coalition (CFHCC), a 128-member

nonprofit business health care group, have been using CAHPS® for 3 years to improve the quality of

the health care plans that serve their employees. After CAHPS® surveys are completed and the

results are analyzed, CFHCC members focus on areas with low scores in patient satisfaction to

identify and improve areas that scored poorly with employees. 

In health care policymaking:

• A new tool developed by AHRQ-supported researchers, the function-related groups (FRGs), can

distinguish accurately between patients who need more complex and long-term services and those

whose rehabilitation is likely to require less time. 

• The Health Care Financing Administration has adopted a modified version of FRGs as the basis of

Medicare payments to rehabilitation hospitals because FRGs can promote efficiency without giving

hospitals an incentive to avoid or undertreat patients with complex needs. 

• The Uniform Data System for Medical Rehabilitation (UDSMR) has incorporated FRGs into its data

systems. Some 1,400 medical rehabilitation providers in the United States and other countries use

this data system for continuous quality improvement, outcomes management, research, and other

purposes.
of diabetes measures, some of which are based

on research on diabetes outcomes produced by

AHRQ’s Diabetes Patient Outcomes Research

Team.

A “Patient Pointer” guide developed by the

Memphis Veterans Affairs Medical Center,

which outlines the pros and cons of prostatespecific antigen (PSA) testing for prostate

cancer, is based on the findings of AHRQ

research on the outcomes of treatment for

prostate diseases.

AHRQ research provides data that Federal

agencies use to make estimates of health care

use and expenditures for many purposes. Data

from AHRQ’s Medical Expenditure Panel

Survey (MEPS) and Healthcare Cost and

Utilization Project (HCUP) are used by

agencies ranging from the Congressional

Budget Office and the Council of Economic

Advisors to the Health Care Financing

Administration and the Department of the

Treasury. AHRQ analyses (based on MEPS

data) of the number of children who potentially

are eligible for public insurance programs but

are not yet enrolled have catalyzed Federal

efforts to encourage more effective State

outreach to uninsured, low-income families

with children.

AHRQ’s Research Portfolio: 

A Pipeline of Investment

The key to the success of AHRQ’s program is

that the research is driven by the needs of its

customers. AHRQ seeks input from its customers

in a variety of ways, including: the National

Advisory Council, meetings with stakeholder

groups, Federal Register notices, and through

comments submitted by the public via the Agency’s

Web site (www.ahrq.gov). 

AHRQ’s research agenda is reflected in a

“pipeline” of activities that together build the

infrastructure, tools, and knowledge for measurable

improvements in America’s health care system. This

pipeline builds on the foundation laid by

biomedical science in determining which

interventions can work under ideal circumstances.

But knowing that these interventions work is only

a first step. More work is needed to ensure that

these treatments are used correctly to improve

patients’ health and that they are effective in

everyday practice. AHRQ’s pipeline has the

following segments that provide the steps needed

to achieve these goals.

1. New research on priority health issues. The

first segment of the pipeline supports new

research to answer important questions about

what works in health care. The effort helps

build the essential knowledge base that enables

us to understand the determinants of the

7

Quality Research for Quality Health Care

IMPROVED OUTCOMES BETTER QUALITY

APPROPRIATE COST AND USE GREATER ACCESS

New Knowledge

on Priority 

Health Issues

New Tools and 

Talent for a

New Century

Translating

Research Into

Practice

The Research Pipeline
outcomes, quality, accessibility, and costs of

care, as well as identify instances when care falls

short of achieving its intended outcomes.

2. New tools and talent for a new century. The

second segment of the pipeline is the

development of tools to apply the knowledge

gained through the investment in new research.

Here, the work of researchers is applied, and

the effort begins to translate this new

knowledge into instruments for measurement,

databases, informatics, and other applications

that can be used to assess and improve care. In

addition, the individuals who conduct this

research and those who use it are educated to

build an effective workforce of doers and users

of health care research.

3. Translating Research into Practice. The final

segment of the pipeline is where all the previous

investment comes together. Research from the

first segment of the pipeline and the tools

developed in the second segment are translated

into resources to close the gap between what we

know and what we can do to improve health

care quality. In this third segment of the

pipeline, AHRQ funds research and

demonstrations to translate the knowledge and

tools into measurable improvements in the care

Americans receive. The Agency also develops

partnerships with public- and private-sector

organizations to disseminate the knowledge and

tools for use throughout the health care system.

This third segment of the pipeline is a central

focus of the Agency through its Translating

Research Into Practice (TRIP) initiative aimed

at implementing evidence-based tools and

information in diverse health care settings

among practitioners caring for diverse

populations. The theme of translating research

into practice is woven throughout all the

initiatives undertaken by AHRQ in FY 1999-

2000.

AHRQ Cycle of Research

In order to produce meaningful contributions

to health care, AHRQ must set and monitor

priorities, develop research initiatives based on

those priorities, and keep a close watch on the

processes and products that result from agencysupported research. Four processes are involved in

the AHRQ research cycle: needs assessment,

knowledge creation, translation and dissemination,

and evaluation.

Needs assessment. AHRQ’s activities begin

and end with the end-users of its research. Our

research agenda is based on an assessment of gaps

in the knowledge base and the needs of patients,

clinicians, health care managers, institutions, plans,

purchasers, and State and Federal policymakers for

evidence-based information. Needs assessment

helps us shape the research initiatives undertaken

by the agency.

Knowledge creation. AHRQ continues to

support and conduct research to produce the

knowledge needed to improve the health care

system in the coming years. 

Translation and dissemination. Simply

producing knowledge is not enough. Findings

must be presented in ways that are useful and

made widely available to clinicians, patients, health

care managers, and other decisionmakers. AHRQ

synthesizes and translates knowledge into products

and tools that help our customers solve problems

and make decisions. We are proactive in our

dissemination of the knowledge, products, and

tools to appropriate audiences, and we form

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E

K

N

D

Needs

assessment

Translation and

dissemination

Evaluation

Knowledge

creation

Cycle of Research
partnerships with other organizations to leverage

our resources.

Evaluation. To assess the ultimate outcomes of

AHRQ research, we evaluate the impact and

usefulness of agency-supported work in health care

settings and policymaking. This involves a variety

of evaluation activities, including smaller, shortterm projects that assess processes, outputs, and

interim outcomes to larger, retrospective projects

that assess the ultimate outcomes and impact of

AHRQ activities on the health care system.

Opportunities for Research 

The mission of AHRQ could not be achieved

without talented health services researchers who are

dedicated to excellence in research. They

understand the importance of evidence to inform

decisionmaking and improve health care quality. In

addition to the researchers on AHRQ’s staff, nearly

two-thirds of the Agency’s budget is awarded as

grants and contracts to support the work of

researchers at universities and research institutions

around the country. 

AHRQ’s research funds are awarded either

through targeted announcements that address

specific research questions or in response to ideas

generated by researchers on significant issues in the

health care system. Both of these mechanisms—

targeted research requests and unsolicited

investigator-initiated research proposals—are

important and complementary. The Agency’s

targeted research initiatives respond to the specific

needs of individual customers or the needs of the

health care system as a whole, although researchers

have latitude to design their own projects within

the scope of a targeted request. 

Investigator-Initiated Research

The topics addressed by unsolicited

investigator-initiated research proposals reflect

cutting-edge issues and ideas from the top

researchers in the field of health services research.

About half of the grants and cooperative

agreements funded by AHRQ in FY 2000 were in

response to program announcements and initiated

by individual investigators who developed research

proposals within an area of interest to the agency.

These are some examples of recent AHRQsupported investigator-initiated research. Examples

from other investigator-initiated projects are

scattered throughout this report.

• Researchers at the University of Alabama at

Birmingham have found that one-third of all

patients suffering a heart attack don’t have chest

pain and thus may delay seeking life-saving

treatment. In this study, patients who were

suffering a heart attack but did not have chest

pain arrived at the hospital 3 hours later than

patients with chest pain. They also were less

likely to be diagnosed with a heart attack at

hospital admission and were twice as likely to

die while in the hospital. 

• The same Alabama researchers have found that

on average only 57 percent of all patients who

are eligible for reperfusion therapy to reopen a

clogged artery—either thrombolytic drugs or

angioplasty—actually receive this lifesaving

treatment. And, the likelihood of receiving

reperfusion therapy varies substantially

according to the patient’s race. Black patients—

particularly black women—are significantly less

likely to receive reperfusion therapy than white

men (44 percent vs. 59 percent, respectively). 

• A recent study by researchers at the University

of Colorado found that monthly recertification

of Medicaid eligibility leads to frequent shifts

on and off the program and may undermine

delivery of quality health care for children.

About one in five U.S. children is enrolled in a

State Medicaid program. These researchers used

children’s access to care and treatment for

middle ear infection to examine the effects of

Medicaid recertification on quality of care.

They found that children who are continuously

enrolled in Medicaid throughout the year are

much more likely to have an assigned primary

care physician and receive better care for

middle ear infections, less likely to visit a

hospital emergency department for the

condition, more likely to fill antibiotic

prescriptions, and more likely to be referred for

needed ear surgery, such as tube placement or

adenoidectomy.

9

Quality Research for Quality Health Care
• Many studies have pointed to the link between

nurse staffing levels and nursing home quality

of care. However, researchers at the University

of California, San Francisco, have found that

nursing home characteristics and geographic

location are more predictive of nursing home

care deficiencies than staffing hours or resident

characteristics. They examined the data

reporting system for all U.S. certified nursing

homes and found that fewer RN hours and

nursing assistant hours were associated with

total deficiencies and quality of care

deficiencies. However, staffing hours alone

predicted less than 1 percent of the total

variance in deficiencies. Staffing and resident

characteristics together explained 3 percent of

the variance. Adding facility characteristics and

region to the mix increased the proportion of

variance explained to 21 percent. Facilities that

were smaller and nonprofit or governmentowned had fewer deficiencies, and facilities with

a higher percentage of Medicaid residents had

more deficiencies. 

• In half of the cases of out-of-hospital cardiac

arrest that occurred in Seattle over the past few

decades and were witnessed by bystanders, the

victims did not receive bystander-initiated

CPR. In this study, the researchers randomly

assigned 241 out-of-hospital cardiac arrest

patients to receive chest compression alone and

279 to receive chest compression plus mouthto-mouth ventilation. Emergency medical

dispatchers gave bystanders instructions during

62 percent of episodes for chest compression

plus mouth-to-mouth ventilation (about 2.4

minutes for instruction) and in 81 percent of

episodes for chest compression alone (only 1

minute of instruction). The outcomes for

people who were administered CPR according

to instructions given by the emergency medical

dispatcher were virtually the same after chest

compression alone as after chest compression

with mouth-to-mouth ventilation. 

Targeted Research Requests

In FY 1999, AHRQ announced six Requests

for Applications (RFAs) on questions critical to the

health care system. Another six RFAs were

announced in FY 2000.

FY 1999 RFAs

1. Health Care Access, Quality, and Insurance

for Low-Income Children. AHRQ teamed

with the David and Lucile Packard Foundation

and the Health Resources and Services

Administration to fund studies that will help

public health insurance programs and delivery

systems improve the quality of and access to

care for low-income children. Researchers

funded under this RFA are focusing on

minority children and those with special needs.

2. Development of Quality of Care Measures

for Vulnerable Populations. This RFA focused

on the development and testing of measures

that can be used in the purchase or

improvement of health care services for

populations identified as vulnerable under the

definition outlined by the President’s Advisory

Commission on Consumer Protection and

Quality in the Health Care Industry. According

to this definition, a person may be vulnerable

because of financial status or place of residence,

health, age, functional or development status,

ability to communicate effectively, chronic or

terminal illness, disability, or personal

characteristics. 

3. Translating Research into Practice. This RFA

supported projects that explore strategies for

implementing research findings and evidencebased tools in everyday clinical practice.

Evidence-based tools include clinical practice

guidelines, practice parameters, quality

indicators, and continuous quality

improvement initiatives developed using a

systematic approach to evidence synthesis. 

4. Quality Improvement. The goal of this

initiative was to strengthen the evidence base

underlying the choice of strategies to improve

the quality of health care, particularly in areas

where the greatest improvement in health and

functional status can occur. Studies funded

under this RFA are evaluating strategies for

improving health care quality that currently are

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being used widely by organized quality

improvement systems. 

5. Centers for Education and Research in

Therapeutics. This RFA announced the

Agency’s intention to establish Centers for

Education and Research in Therapeutics

(CERTs) to develop, translate, and disseminate

objective information on therapeutics to health

care providers and other decisionmakers to

improve practice. These Centers are conducting

state-of-the-art research to increase awareness of

new uses of drugs, biological products, and

devices; identify ways to improve their effective

use; and examine the risks associated with new

uses and combinations of drugs and biological

products. The Centers also will help improve

heath care quality while reducing costs by

increasing the appropriate use of drugs,

biological products, and devices and identifying

ways to prevent potential adverse effects.

[Editor’s note: See pages 16 and 17 for a listing

of CERTs funded under this RFA.]

6. Market Forces. Through this RFA, AHRQ

provided support for Centers of Excellence that

conduct research on how health care market

forces are affecting the quality of health care,

access to health care services, and the cost of

care. Findings from studies conducted by these

centers will help public policymakers

understand, monitor, and anticipate changes in

the Nation’s market-driven health care system.

The projects include special emphasis on

market effects on rural and minority

populations and the influence of purchasers in

local markets.

FY 2000 RFAs

1. Quality information for consumers and

patients. This RFA was issued jointly by

AHRQ and the National Cancer Institute. It

announced support for demonstration projects

to (1) identify and test methods and models for

developing information on quality for use by

consumers and patients in making health care

decisions and (2) evaluate the impact of

providing consumers and patients with quality

information. Special emphasis was placed on

populations made vulnerable by personal

characteristics (e.g., race or sex), low income,

place of residence (i.e., rural), poor health

status, age, problems in communicating, or

functional status. 

2. Minority health disparities. This RFA

announced AHRQ’s interest in funding projects

to analyze the causes and contributing factors

associated with racial/ethnic disparities in

burden of illness, death, and health care access,

use, quality, and outcomes. The projects also

will identify and implement strategies to

eliminate such disparities in six clinical areas:

infant mortality, cancer screening and

management, cardiovascular disease, diabetes,

HIV, and immunizations for children and

adults. 

3. Primary care practice-based research

networks. This RFA announced funding for a

series of 1-year exploratory grants to assist new

or established practice-based research networks.

The goal is to help them enhance their capacity

to conduct research in primary care settings and

translate research findings into practice.

4. Violence against women. This initiative called

for research on the outcomes, effectiveness, and

cost-effectiveness of programs for early

identification and treatment of domestic

violence against women. Goals are to develop

new knowledge on the prevention of domestic

violence, find better ways to identify female

patients at risk, and evaluate outcomes and

effectiveness of health care interventions to treat

violence victims.

5. Improving patient safety. This RFA

announced AHRQ’s interest in funding

cooperative agreements to test the effectiveness

of “best practices” to improve patient safety by

reducing preventable, systems-related medical

errors that have a high prevalence and severe

consequences. 

6. Translating research into practice II. This

RFA invited applications for cooperative

agreement demonstration projects to evaluate

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Quality Research for Quality Health Care
strategies for translating research into practice

through the development of partnerships

between researchers and health care systems and

organizations. Such systems and organizations

include purchaser groups, integrated health

service delivery systems, academic health

systems, HMOs and other managed care

programs, practice networks, and worksite

clinics. The goal is to accelerate and magnify

the impact of research on clinical practice and

patient outcomes in applied settings.

Nurturing Research Career

Development

AHRQ contributes to excellence in health care

delivery through research conducted by a cadre of

well-trained and talented health services

researchers. To maintain and nurture this vital

resource, the Agency supports a variety of training

and career development opportunities through

individual and institutional grant programs. These

include:

• Dissertion research support.

• Predoctoral fellowships for minority students.

• National Research Service Awards

(pre- and postdoctoral fellowships).

• Independent Scientist Awards (K awards).

• Innovative Incentive Awards.

In FY 1999 and FY 2000, AHRQ:

• Supported 167 pre- and postdoctoral students

through institutional and individual National

Research Service Awards and dissertation

grants.

• Increased support by about 25 percent for preand postdoctoral trainees and fellows.

• Provided support for 218 scholars in FY 2000.

• Launched two new career development

programs: the Independent Scientist Award and

the Mentored Clinical Scientist Development

Award, which supported 16 additional scholars.

• Initiated a variety of activities to increase

cohesiveness and build an infrastructure among

AHRQ training programs, including annual

meetings of students and faculty and enhanced

Web-based information and links.

• Instituted the Kerr White Visiting Scholar

program through which health services

researchers work in residence at AHRQ and

collaborate with Agency research staff.

Additional information on all of the Agency’s

funding opportunities—including an ongoing

program announcement that describes the

priorities for investigator-initiated research, targeted

initiatives, and career-related grant programs—is

available at www.ahrq.gov/fund.

Partnerships and Coordination

AHRQ works in partnership with many other

agencies and organizations. These include the

various HHS agencies, other components of the

Federal Government, State and local governments,

and private-sector organizations, all of whom help

the agency achieve its goals. 

Most of the agency’s partnerships are related to

the development of new knowledge, development

of tools and other decision-support mechanisms,

and/or the translation of research findings into

practice. Examples of this collaboration include

efforts to:

1. Develop new knowledge through research.

– AHRQ co-funds individual research projects

and sponsors joint research solicitations with

other HHS agencies.

– AHRQ recently co-funded research with the

David and Lucile Packard Foundation and

HRSA on the impact of public insurance

programs and delivery systems on access to

care and quality of care for low-income

children.

2. Develop tools, measures, and decision-support

mechanisms.

– The Health Resources and Services

Administration (HRSA) and AARP worked

in partnership with AHRQ to develop

Staying Healthy at 50+, the newest resource

in the Put Prevention into Practice program.

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– Many agencies (e.g., the National Institutes

of Health, the Health Care Financing

Administration, and the Department of

Veterans Affairs) are working closely with

AHRQ’s evidence-based practice centers

(EPCs) to develop assessments of existing

scientific evidence to guide their work.

– Evidence reports prepared by AHRQsupported EPCs are being used in the

development of clinical practice guidelines

by a number of organizations, including the

American Psychiatric Association, the

American Academy of Pediatrics, the

American Heart Association, and many

others.

– The Healthcare Cost and Utilization Project

(HCUP) is a long-standing partnership

between AHRQ and 22 States to build a

multi-State data system.

3. Translate research into practice.

– AHRQ has joined with 14 companies and

organizations to disseminate a tool to help

individuals apply research findings on

quality measures and make major decisions

about health plans, doctors, treatments,

hospitals, and long-term care. Some of

AHRQ’s partners in this endeavor are IBM,

United Parcel Service, and the Midwest

Business Group on Health.

– A number of companies and organizations

have joined AHRQ in disseminating

smoking cessation materials. These include

the American Cancer Society, the American

Academy of Pediatrics, and the Michigan

Department of Community Health.

4. Update the Public Health Service smoking

cessation guideline.

– In FY 2000, a consortium of seven Federal

Government and nonprofit organizations,

including AHRQ, joined together to

sponsor the development and release of a

clinical practice guideline and related

materials on smoking cessation. Treating

Tobacco Use and Dependence presents

evidence about new, effective clinical

treatments for tobacco dependence,

including cigarettes, cigars, and other forms

of tobacco. It includes recommendations for

health care providers with brief supporting

information, tables and figures, and

pertinent references. In addition to the

Public Health Service guideline itself, a

quick reference guide presents summary

information for day-to-day use by clinicians,

and a consumer guide provides information

for the general public.

Strategic Plan and Goals 

For the last several years, the Agency has been

engaged in a comprehensive process which

culminated in the development of a strategic plan

that will serve as a road map as we carry out our

mission. This process involved an extensive review

of AHRQ’s activities and input from major

stakeholders in the health care system: AHRQ’s

customers, the agency’s National Advisory Council,

Congress, and the Department of Health and

Human Services. AHRQ staff members were

heavily invested in the planning process from

developing personal strategic and performance

plans to contributing to the development of the

strategic plan for their Offices and Centers. 

As part of this process, each year—during

annual planning and budget development

activities—AHRQ assesses the progress the Agency

has made toward achieving each of the goals. To do

this, measurable Agency-level evaluation

parameters have been developed to determine

whether AHRQ has achieved its objectives in

knowledge development, translation,

dissemination, and evaluation. These parameters

are an integral part of AHRQ’s compliance with

the Government Performance and Results Act of

1993 (GPRA) and are detailed in the annual

GPRA performance plans submitted with each

annual budget request.

AHRQ’s strategic plan supports the

achievement of three goals, which together meet

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Quality Research for Quality Health Care
the challenge laid out by the Agency’s mission.

Activities supported under each goal meet the

criteria of one or more segments of the research

pipeline. The goals are:

1. Support improvements in health outcomes.

2. Strengthen quality measurement and

improvement.

3. Identify strategies to improve access, foster

appropriate use, and reduce unnecessary

expenditures.

Goal 1: Support Improvements in

Health Outcomes

AHRQ has a 10-year tradition of supporting

research that builds the fundamental evidence base

on the outcomes and effectiveness of health care. A

high priority for the Agency’s outcomes research

portfolio is the study of clinical conditions that are

common, expensive, and/or for which there are

significant variations in practice or opportunities

for improvement. AHRQ also supports outcomes

research on major organizational changes or

innovations to the health care system and the

processes by which health care services are

delivered. An important component of this goal is

that research supported must incorporate the

patient’s perspective in the assessment of

effectiveness. 

Outcomes research answers a number of very

basic questions for the health care system: What

works and doesn’t work? Is it having the desired

impact? Does it provide value for the money spent?

The answers to these questions are the building

blocks for the health care system’s effort to improve

access to health care and its cost, use, and quality. 

Outcomes Research Portfolio

In FY 1999, AHRQ focused its outcomes

portfolio on health care for the chronically ill and

elderly by publishing a special emphasis notice and

by encouraging health services researchers to

submit proposals in this area. Examples of funded

projects include the following studies:

• Improving the quality of initial pneumonia

care. This study is examining strategies guiding

clinical decisions regarding which patients with

community-acquired pneumonia require

hospitalization and which can be safely treated

at home. For patients who do require hospital

admission, the researchers will evaluate and

implement strategies to improve the quality of

hospital care. (University of Pittsburgh, in

collaboration with quality-improvement

organizations in Pennsylvania and

Connecticut). 

• Identification of clinically relevant changes

in health-related quality of life. This project is

evaluating patient-reported outcome measures

for three common chronic conditions (heart

failure, chronic lung disease, and asthma) to

determine their value for clinicians and

patients. (St. Louis University). 

• Automated assessments and the quality of

diabetes care. This study is evaluating the

variation in outcomes for patients with diabetes

using an automated telephone

disease-management system. Half of the

patients primarily speak Spanish; the other half,

primarily English. A rich array of information

will be collected and assessed to predict adverse

outcomes. (Palo Alto Institute for Research,

Palo Alto, CA). 

• Inguinal hernia management: Watchful

waiting vs. operation. Inguinal hernia is one

of the most common conditions affecting men

around the world; approximately 700,000

herniorrhaphies are performed in the United

States each year. The indications for surgical

repair of a minimally symptomatic hernia are

vague, and it is not known whether patients

with inguinal hernias can safely delay surgical

treatment. This study is testing the safety and

outcomes of watchful waiting, which could

change the management of many men with

minimally symptomatic hernias. (American

College of Surgeons, Northwestern University,

and the VA Cooperative Studies).

In FY 1999, AHRQ released an extensive

evaluation of its past decade of outcomes research.

This evaluation, The Outcomes of Outcomes

Research, was developed with input from

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researchers and the users of outcomes research. It

includes an evaluation of past projects funded by

the Agency and a preliminary examination of their

impact on the Nation’s health care system.

According to the report, outcomes research

supported by the Agency has provided descriptive

information that has challenged prevailing clinical

ideas about the management of specific clinical

conditions. In addition, AHRQ’s outcomes

research has resulted in tools, guidelines, and

strategies that improve the treatment of common,

costly medical conditions.

U.S. Preventive Services Task Force 

The U.S. Preventive Services Task Force

(USPSTF) is another critical source of information

on what does and does not work in the health care

system specific to prevention. First convened in

1984, the USPSTF is an independent panel of

preventive health experts. The Task Force is

charged with evaluating the scientific evidence for

the effectiveness of a range of clinical preventive

services—including common screening tests,

immunizations, and counseling for health behavior

change—and producing age- and

risk-factor-specific recommendations for these

services. The Task Force published its first set of

recommendations in the 1989 Guide to Clinical

Preventive Services, which was subsequently revised

in 1995. 

The third USPSTF was convened in early FY

1999 and has begun work on 12 initial topics

selected by Task Force members based on

preliminary work by two of AHRQ’s Evidencebased Practice Centers: the Research Triangle

Institute/University of North Carolina at Chapel

Hill and the Oregon Health Sciences University.

The selection process included a preliminary

literature search of new information on prevention

and screening published since 1995; consultation

with professional societies, health care

organizations, and outside prevention experts; a

review of current levels of controversy and variation

in practice; and consideration of the potential for a

change from the 1995 USPSTF recommendations. 

The 12 topics are:

• Chemoprophylaxis (for example, tamoxifen and 

related drugs) to prevent breast cancer (new

topic).

• Vitamin supplementation to prevent cancer or

coronary heart disease (vitamin E, folate, beta

carotene, and vitamin C) (new topic).

• Screening for bacterial vaginosis in pregnancy 

(new topic).

• Developmental screening in children (new

topic).

• Screening for diabetes mellitus (updated topic).

• Newborn hearing screening (updated topic).

• Screening for skin cancer (updated topic).

• Counseling to prevent unintended pregnancy 

(updated topic).

• Screening for high cholesterol (updated topic).

• Postmenopausal hormone therapy (updated

topic).

• Screening for chlamydial infection (updated

topic).

• Screening for depression (updated topic).

Put Prevention Into Practice

AHRQ’s Put Prevention Into Practice (PPIP)

program helps translate the evidence-based

recommendations of the U.S. Preventive Services

Task Force into practice through the development

and dissemination of resources for providers,

patients, and office systems. PPIP emphasizes the

importance of a comprehensive, system-wide, team

approach to delivering effective preventive

interventions. AHRQ works closely with public

and private partners to disseminate PPIP resources.

PPIP materials include information on preventive

services recommendations, ideas for

implementation, flowsheets, posters, and personal

health guides. 

During FY 2000, work was completed on

Staying Healthy at 50+. This new guide is available

in English and Spanish. It contains tips and

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Quality Research for Quality Health Care
recommendations on health habits, screening tests,

and immunizations to help people age 50 and

older stay healthy. Staying Healthy at 50+ was

developed by AHRQ in partnership with AARP

and the Health Resources and Services

Administration. Print copies of the guide are

available from the AHRQ Clearinghouse (800-

258-9295), and it is available online at AHRQ’s

Web site. Go to www.ahrq.gov and click on

“consumers and patients” and then “prevention and

wellness” to access the file.

Evidence-based Practice Centers 

AHRQ’s 12 Evidence-based Practice Centers

(EPCs) develop evidence reports and technology

assessments on conditions and technologies that are

costly, common, and/or significant for the

Medicare and Medicaid populations. These reports

and technology assessments are based on rigorous,

comprehensive reviews of relevant scientific

literature, and they emphasize explicit and detailed

documentation of methods, rationale, and

assumptions. The goal of these reports is to provide

the scientific foundation that public and private

organizations can use to develop their own clinical

practice guidelines, quality measures, review

criteria, and other tools to improve the quality and

delivery of health care services. Professional

organizations, health plans, providers, and others

who nominate topics are considered partners, and

they agree to use the evidence reports when they

are completed. Eleven evidence reports were

released in FY 1999:

• Diagnosis of Sleep Apnea.

• Traumatic Brain Injury.

• Traumatic Brain Injury in Children and

Adolescents.

• Pharmacotherapy for Alcohol Dependence.

• Advanced Prostate Cancer.

• Cervical Cytology.

• Urinary Tract Infections in Paralyzed Persons.

• Depression—New Pharmacotherapies.

• Swallowing Disorders in Stroke Patients.

• Acute Bacterial Rhinosinusitis.

Nineteen new evidence topics were announced

in FY 1999. For the first time, the EPCs began

tackling some nonclinical topics in addition to

high priority clinical questions. Examples of reports

currently in development or in press include:

• Refinement of AHRQ’s HCUP Clinical

Quality Indicators, University of California,

San Francisco (UCSF)-Stanford University, Palo

Alto, CA.

• Medical Informatics and Telemedicine

Coverage under Medicare, Oregon Health

Sciences University, Portland OR.

• Complementary and Alternative Medicine,

University of Texas Health Science Center, San

Antonio, TX.

• Criteria for Referral of Patients with Epilepsy,

Metaworks, Boston MA.

• Diagnosis and Management of Osteoporosis,

Oregon Health Sciences University, Portland

OR.

• Treatment of Pulmonary Disease Following

Spinal Cord Injury, Duke University, Durham,

NC.

• Management of Acute Chronic Obstructive

Pulmonary Disease, Duke University, Durham,

NC.

• Criteria for Determining Disability in Patients

with End-Stage Renal Disease, ECRI,

Plymouth Meeting, PA.

• Treatment of Acne, Johns Hopkins University,

Baltimore, MD.

• Anesthesia Management During Cataract

Surgery, Johns Hopkins University, Baltimore,

MD.

• Management of Acute Otitis Media, Southern

California EPC/RAND, Santa Monica, CA.

Centers for Education and Research

on Therapeutics

In FY 1999, AHRQ announced funding of

four Centers for Education and Research on

Therapeutics (CERTs). As described earlier, the

CERTS will disseminate information on

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therapeutics to health care providers and other

decisionmakers. The Agency was given initial

authority to support the CERTS initiative under

the Food and Drug Modernization Act of 1997. In

FY 2000, AHRQ added three additional centers to

expand the program and help researchers tackle the

complicated and difficult issues involved in the safe

and effective use of medical products.

The CERTs and their principal investigators

are:

• Duke University Clinical Research Institute

Cardiovascular CERT. This center focuses on

currently approved therapies in cardiovascular

medicine, including special surveillance

programs for cardiovascular devices,

revascularization, new prosthetic valves, and

coronary stents. In addition, the center

conducts demonstration projects involving the

treatment of congestive heart failure, chest pain,

and abnormal heart rhythms.

• University of North Carolina CERT on

Rational Therapeutics for the Pediatric

Population. Improvement in child health is the

focus of this center. Activities include

innovative education and research on new drugs

and devices used in pediatric care and new uses

of existing drugs and devices. Potential study

topics include therapeutic drug monitoring in

HIV-infected children, drug metabolism,

vitamin D deficiency (rickets), asthma care,

attention deficit/hyperactivity disorder, and

adverse drug reactions in children.

• Vanderbilt University CERT. The goal of this

center is to improve use of prescription

medicines in Medicaid managed care by

addressing three specific threats to rational

pharmacotherapy: inadequate knowledge of

medications and their benefits and risks,

inappropriate provider and patient behavior,

and policies that lead to poor patient outcomes.

A major focus of this project is the treatment of

arthritis.

• Georgetown University CERT. This CERT

focuses on reducing drug interactions,

particularly in women, by improving

prescribing practices. Objectives include

identifying potential candidates for

investigations of drug interactions and

designing and implementing a comprehensive

educational program on specific drug

interactions aimed at physicians, pharmacists,

and patients.

• Harvard Pilgrim Health Care CERT. This

CERT is developing and testing the usefulness

of large databases for studying the effectiveness

and safety of antibiotic use in children, drugs

for preventing congestive heart failure, and

hypoglycemic medications in people with

diabetes. 

• University of Pennsylvania CERT. Principal

investigator Brian Strom, M.D. Total projected

funding $1,391,164. Project period 9/1/00 -

8/31/03. This CERT is studying ways to reduce

resistance to antimicrobial drugs and carrying

out other research, such as studies on drug use

and subsequent intervention, research on

medication safety, efficacy and effectiveness

research, and methodology studies.

• University of Alabama at Birmingham CERT.

This CERT is studying therapeutics used for

rheumatoid arthritis, osteoporosis, and other

musculoskeletal diseases, including their cost

effectiveness and effects on health-related

quality of life, as well as ways to minimize any

adverse effects associated with their use.

Translating Research into Practice

(TRIP)

There have been significant advances in science

in the last few years, yet not enough of this

knowledge has been put to work in daily clinical

practice. There is a gap between what we know and

what we do. One consequence of this gap is the

wide variation in the quality of care from one

clinician to another and from one area of the

country to another. Variations in health care can

contribute to a higher mortality rate and billions of

dollars in wasted spending. 

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Quality Research for Quality Health Care
As a nation, we need to step up our efforts to

address this variation, particularly since it takes

between 6 and 10 years for clinical practice to

adopt new knowledge for most patients. AHRQsupported research is working toward this goal. We

have a growing agenda to accelerate the translation

of research into clinical practice. AHRQ is

committed to informing practitioners, patients,

consumers, and other decisionmakers about needed

changes in health care as revealed through research.

A key challenge is to identify more effective

strategies for change and facilitate the adoption and

use of research findings. 

In FY 2000, AHRQ published a solicitation,

known as TRIP II, to help accelerate the impact of

research on practice. The goal was to stimulate

research to improve our understanding of which

quality improvement efforts work and in which

situations, in what kind of systems, for which types

of patients, and under which circumstances. The

agency funded 13 new TRIP II grants in FY 2000.

Examples of funded projects include:

• An Internet intervention to increase

chlamydia screening. This is a randomized

trial in the offices of 220 primary care

physicians to test Internet-based learning

modules for physicians that are designed to

increase screening of at-risk patients and

decrease the incidence of pelvic inflammatory

disease.

• Better use of ischemic stroke research. These

researchers are assessing the use of evidencebased treatment guidelines for acute ischemic

stroke in 24 urban and rural hospitals in

Minnesota.

• Better pediatric outcomes through improved

chronic care. The goal is to reduce costs by

using affordable technology to improve asthma

care for poor, inner city, minority children aged

5-18 who are enrolled in a community health

center-based Medicaid managed care

organization.

• Use of multimedia for educating vulnerable

populations about diabetes. The researchers

are comparing usual care with patient education

through the use of an interactive, multimedia

computer program to improve diabetes-related

knowledge, attitudes, and compliance with selfcare recommendations.

• Improved pain management in nursing

homes. The goal is to develop educational

materials, improve quality of pain assessment

and management procedures, improve

knowledge and attitudes toward pain, and assess

the cost-effectiveness of the intervention to

nursing homes.

• Improved quality with outpatient decision

support. The researchers will test physician

compliance with paper-based and electronic

guidelines, reminders, and alerts for outpatient

settings. The reminders and alerts will focus on

disease and medication management and test

ordering.

Integrated Delivery System Research

Network

The Integrated Delivery System Research

Network (IDSRN) is a new model of field-based

research developed by AHRQ in FY 2000 to link

the Nation’s top researchers with some of the

largest health care systems to conduct fast-track

research on cutting-edge issues in health care. The

goal is to determine what works in terms of data

and measurement systems, and identify

organizational ‘best practices’ related to care

delivery and research diffusion. The IDSRN

comprises a cadre of delivery-based researchers and

sites to test ways to adapt and apply existing

knowledge in real world settings.

Together, the members of the IDSRN provide

health services in a wide variety of organizational

care settings to over 34 million Americans. The

populations served include privately insured

individuals, Medicare and Medicaid patients, the

uninsured, ethnic and racial minorities, and rural

and inner-city residents. Each of the nine IDSRN

partners has the following three attributes:

• Data availability. IDSRN partners collect and

maintain administrative, claims, encounter, and

other data on large populations that are

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clinically, demographically, and geographically

diverse.

• Research expertise. IDSRN partners include

some of the country’s leading health services

researchers, with proficiency in quantitative and

qualitative research and expertise in emerging

areas that have critical policy or managerial

implications. 

• Authority to implement a health care

intervention. IDSRN partners are responsible

for managing delivery systems and are in a

position to implement financial and

organizational strategies.

Ten research projects are underway, with total

funding of approximately $2.4 million. Project

timelines range from 9 to 30 months. IDSRN

projects can be divided into two categories–data

and measurement capacity and care delivery.

Three of the IDSRN projects involve data and

measurement capacity and will:

1. Build capacity to study racial/ethnic disparities

in access, use, and outcomes. 

2. Validate the Agency’s HCUP Quality

Indicators, a software tool that can be used with

hospital administrative data for hospital selfassessment. 

3. Evaluate the potential of private-sector data to

augment public data for use in assessing the

state of health care quality in the United States. 

Seven IDSRN projects will collect, test, and

apply evidence about how to structure health care

delivery, as follows:

1. Assess variations in quality of care for the

management of cardiovascular disease and its

risk factors, including those related to race, sex,

or socioeconomic status. 

2. Assess the impact of organizational

interventions on quality of care and efficiency. 

3. Advance understanding of which hospital

policies and practices underlie the volumeoutcomes association for certain complex

procedures. 

4. Determine how and to what extent health plans

include quality-related provisions in their

contracts with hospitals and other providers. 

5. Track and evaluate how a clinical practice

guideline is implemented by a health plan. 

6. Identify barriers to the use of information

technology within delivery systems. 

7. Examine the delivery system’s capacity for

responding to public health threats, including

those related to bioterrorism. 

National Guideline Clearinghouse 

While developing the evidence-based

foundation for improved health care is an

important first step, a critical next step is to make

the information available to the people who need it

promptly and in an appropriate format. In January

1999, AHRQ debuted the National Guideline

Clearinghouse® (NGC), a comprehensive,

publicly available online repository of evidencebased clinical practice guidelines and related

materials. The NGC, developed in partnership

with the American Medical Association and the

American Association of Health Plans, includes

standardized abstracts, full text (or links to full

text) of guidelines, and comparisons between

guidelines on similar topics. The guidelines

included in the NGC must meet rigorous criteria.

By the end of FY 2000, the NGC included more

than 850 hundred evidence-based guidelines.

Primary Care Research

AHRQ’s Center for Primary Care Research

(CPRC) is the only research entity in the Federal

Government devoted to the study of primary care.

CPCR conducts and supports studies of primary

care and clinical, preventive, and public health

policies and systems. Findings from this research

shed light on the most common interaction

patients have in the health care system—with their

primary care physicians, nurses and other first-line

providers. CPCR’s research also provides the

information and tools that help primary care

clinicians provide high quality health care services.

For example, primary care research supported by

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Quality Research for Quality Health Care
AHRQ has found:

• Recognizing and treating depression in primary

care can prevent unnecessary hospitalizations

and save money. More than 25 percent of

primary care patients have a diagnosable mental

health disorder (most often anxiety or

depression), and in many cases, these

conditions go undetected and untreated.

Researchers at the University of Rochester

School of Medicine found that patients of

primary care physicians who diagnosed the

greatest number of mental health disorders

among their patients had 9 percent lower

overall health care expenditures and 20 percent

lower inpatient expenditures than patients of

physicians who diagnosed the smallest number

of such disorders. Primary care physicians who

diagnose more mental health disorders in their

patients may recognize when unexplained

medical symptoms are due to emotional distress

or a mental health problem. Thus, they are less

likely to order unnecessary diagnostic tests,

inappropriately refer patients to specialists, or

admit them to the hospital when it is not

necessary.

• Nine of every ten California patients in

managed care plans say that they value having a

primary care doctor provide their everyday care,

and 89 percent say that they value having a

primary care doctor coordinate their specialty

care. But nearly a quarter of the patients

studied had difficulty getting referrals to

specialty care, which, according to the

researchers, is a reason why some patients may

lose trust and confidence in their primary care

doctors.

Goal 2: Strengthen Quality

Measurement and Improvement

AHRQ’s second research goal is the centerpiece

of the Agency’s effort to develop the strategies and

tools that will lead to improvements in the quality

of health care. Under this goal, the Agency is

developing and testing measures of quality and

supporting research on the best ways to collect,

compare, and communicate these data to the

appropriate audiences.

To help ensure that this information is used in

everyday health care practice, AHRQ will also

focus on research that identifies the most effective

ways to improve health care quality, including

promoting the use of information on quality

through a variety of strategies, such as information

dissemination and assessing the impact on health

care organization and financing. 

The Agency funded 24 grants in FY 1999

totaling over $8.8 million to develop new quality

measures and identify strategies for measuring and

improving the quality of health care. These grants

included responses to three RFAs mentioned

earlier: Translating Research into Practice (TRIP);

Quality Measurement for Vulnerable Populations;

and Assessment of Quality Improvement Strategies

in Health Care. 

CAHPS®

In FY 1999, more than 90 million Americans

began using AHRQ’s CAHPS® to help them

decide which health plan would best meet their

health care needs. CAHPS® is an easy-to-use kit of

survey and reporting tools that provides accurate

and useful information to help consumers and

purchasers assess and choose a health plan. 

CAHPS® was used by more than 20 States in

FY 1999 and by corporations such as Daimler

Chrysler, Ford, and GM; health plans; and

employer groups around the country. The Health

Care Financing Administration also began using

CAHPS® to survey Medicare managed care

enrollees. The U.S. Office of Personnel

Management also fielded its first CAHPS®

survey to report consumer assessments of their

health plans to Federal employees for the FY 2000

open season for choosing health benefits.

CONQUEST

In FY 1999, AHRQ released CONQUEST 2.0

(Computerized Needs-Oriented Quality

Measurement Evaluation System). CONQUEST is

a database that helps health care and quality

improvement professionals quickly identify,

understand, compare, evaluate, and select measures

to assess and improve clinical performance in

acute, ambulatory, long-term, and home health

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care settings. The measures cover children and

adults and include many different common and

costly diagnoses and conditions that are, in turn,

linked with evidence-based treatment guidelines.

The new 2.0 version includes more clinical

performance measures and medical conditions than

the previous version, as well as new information on

how to select and apply the measures.

Research on Quality Improvement 

In FY 1999-2000, AHRQ-supported studies

provided insight into the critical issues of health

care quality. Examples of pertinent findings

include:

• Quality reports, or physician profiles, for

diabetes were unable to detect reliably true

practice differences among doctors at three

medical practices—a large, West Coast

staff-model health maintenance organization,

an urban medical school teaching clinic located

in the Midwest, and a group of private-practice

physicians in New England. Differences in how

the physicians managed their patients’ diabetes

contributed only 4 percent at most to the

overall variance in hospitalization rates, office

visits, laboratory use, and blood glucose control

rates. The difficulty in using these outcomes to

evaluate physician performance was due, in

large part, to the relatively small number of

patients with diabetes managed by each doctor. 

• According to five nursing home “stakeholder”

groups—nursing home advocates,

administrators, regulators, ombudsmen, and

nursing service directors—quality of care is the

most important yardstick for assessing nursing

home quality, followed closely by the residents’

quality of life, and then by residents’ rights.

Although the stakeholders agreed on the three

most important categories for measuring

quality, they differed in how they thought each

should be ranked. Nursing home advocates and

nursing directors tended to give quality of care

the highest ranking, while administrators and

State licensing and certification survey agency

training coordinators were more likely to pick

quality of life as the most important category.

State nursing home ombudsmen generally

chose residents’ rights as the most important.

The stakeholders saw the remaining 14

categories considered in this study as being

much less important. 

• Heart bypass surgery patients insured by private

HMOs may get higher quality hospital care in

some areas of the country, while patients in

other areas of the country may get poorer

quality care. HMO patients in California who

underwent heart bypass surgery in 1994 were

more likely to be directed to hospitals with

lower-than-expected death rates for the

operation than non-HMO patients undergoing

the same surgery. California has

long-established managed care markets that are

dominated by large HMOs. But in Florida, a

State in which managed care arrived more

recently and where market areas tend to be

smaller and not dominated by large HMOs, the

researchers found that privately insured HMO

patients were no less likely to use hospitals with

average and high heart bypass surgery rates than

non-HMO patients (those insured through

indemnity and preferred provider organization

[PPO] plans). 

Healthcare Cost and Utilization Project

(HCUP) Quality Indicators (QIs)

In FY 1999, AHRQ released a powerful

software tool that can be applied to routinely

available administrative data from hospitals. The

QIs are an outgrowth of the Agency’s Healthcare

Cost and Utilization Project (HCUP), a

standardized multi-State database of hospital

information developed by AHRQ in partnership

with States and private-sector organizations. See

page 18 for more information about HCUP. 

The QIs can provide initial insight into quality

of care, not only within the hospital but also in

other health care sectors such as ambulatory care.

QIs can be used to derive national and regional

benchmarks against which individual providers,

localities, and States can compare themselves. Also,

with an understanding of the limitations of

administrative data and with appropriate

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Quality Research for Quality Health Care
precautions, the QIs can form a preliminary basis

for a quality improvement program.

For example, the Healthcare Association of

New York State applied HCUP QIs to discharge

data from over 200 of its member hospitals

throughout the State. The association provided

each hospital with a customized report on the

quality of care in that facility, including an analysis

of how it compared with other hospitals. The

customized hospital analyses resulted in a number

of quality initiatives, such as promoting a large

health system to create a regional center of

excellence for the care of patients with diabetes and

a collaboration between the association and its

partners to work to improve adult immunization

rates.

The next generation of QIs is being developed

and enhanced by the UCSF-Stanford Evidencebased Practice Center as follows:

• Add QIs to cover populations and conditions

that are not well represented in the initial

version, specifically pediatric conditions,

chronic illnesses, and technological innovations.

• Provide for population-based denominators

when appropriate.

• Develop a risk-adjustment method for the QIs

to account for differences in case mix across

institutions and communities.

AHRQ’s Leadership in the QuIC 

In FY 1999-2000, AHRQ continued its work

in coordinating the activities of the Federal Quality

Interagency Coordination Task Force (QuIC). The

QuIC was established in 1998 in response to the

final report of the President’s Advisory

Commission on Consumer Protection and Quality

in the Health Care Industry. The QuIC’s goal is to

ensure that all Federal agencies involved in

purchasing, providing, researching, or regulating

health care services are working in a coordinated

way toward the common goal of improving quality

of care. 

The QuIC is co-chaired by the Secretary of

Health and Human Services (HHS) and the

Secretary of Labor (DoL). AHRQ Director John

M. Eisenberg, M.D., serves as operating chair of

the QuIC. In addition to HHS and DoL, the

other Federal members of the QuIC are the

Departments of Defense, Veterans Affairs, and

Commerce; the Office of Personnel Management;

the Office of Management and Budget; the U.S.

Coast Guard, the Federal Bureau of Prisons; the

National Highway Transportation Safety

Administration; and the Federal Trade

Commission. 

Research on Patient Safety and

Medical Errors

According to the Institute of Medicine, as many

as 44,000 to 98,000 people die in hospitals each

year as the result of medical errors. Even at the

lower number, medical errors would be the eighth

leading cause of death in this country, bypassing

motor vehicle accidents, breast cancer, and AIDS.

About 7,000 people each year die from medication

errors alone, which is about 16 percent more

deaths than can be attributed to work-related

injuries.

Clearly, medical errors represent a serious

problem. The good news is that medical errors can

be prevented. Previous agency-supported research

has demonstrated that errors result from system

failures, which can be identified and prevented. In

FY 2000, AHRQ supported research designed to

improve patient safety by identifying and

preventing avoidable system errors. We consider

this a down payment on our future investment in

patient safety research—one that will have a

measurable impact on the quality of care received

by people in this country.

Examples of agency-sponsored patient safety

research now in progress include:

• A study focused on the prevention of medical

errors in emergency department triage and

treatment of acute cardiac ischemia by assessing

the probability that a patient has the condition.

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• A project addressing the impact of electronic

medical records and computerized medication

prescribing on adverse drug events in outpatient

clinics.

• A study looking at ways to improve detection of

adverse drug events through the use of an

automated monitor.

• A project that involves in-depth interviews with

primary care patients and their providers to

elicit their definitions of medical errors and

their experiences with and opinions about such

errors.

• A study using video and audio recordings to

evaluate the procedure used in chest tube

insertion and demonstrate how medical errors

can occur through deviations in process. The

goal is to produce a “best practices” training

guideline to reduce complications from this

procedure.

Goal 3: Identify Strategies to

Improve Access, Foster

Appropriate Use, and Reduce

Unnecessary Expenditures

AHRQ’s third research goal is to support

studies of access, health care utilization, and

expenditures to identify whether particular

approaches to health care delivery and payment

alter behaviors in ways that promote access to care

and/or more economic use of health care resources.

This information is critical because adequate access

and appropriate use of health care services continue

to be problematic for many Americans,

particularly the poor, the uninsured, members of

minority groups, rural and inner city residents, and

other underserved populations. In addition,

changes in the organization and financing of care

have raised new questions about access to a range

of health services, including emergency and

specialty care. 

Research on Priority Populations

AHRQ has always taken steps to ensure that

the Agency’s research emphasizes the needs of

priority populations who generally are underserved

by the health care system and underrepresented in

research. For several years, the Agency has had

cross-cut teams to address three priority

populations: children and adolescents, women, and

minorities. These teams work with all of AHRQ’s

Offices and Centers to ensure that the needs of

these populations are addressed in all of the

Agency’s activities.

In FY 2000, AHRQ began assembling an office

dedicated to research on priority populations.

These include women, children, minorities, the

elderly and aging population, people with

disabilities and/or chronic diseases, people who are

terminally ill, people living in the inner city, 

rural residents, and low-income individuals and

families. AHRQ is focusing special attention on

health care disparities.

Health Care Disparities. Disparities in health

have been documented repeatedly over the last few

decades across a broad range of medical conditions

and affecting many racial and ethnic groups.

Differences have been noted in health outcomes

such as quality of life and mortality, processes of

care such as rates of use of certain services and

procedures, quality and appropriateness of care,

and the prevalence of various conditions and

diseases. 

Disparities persist despite improvements in

health for the Nation as a whole. Between 1987

and 1995, deaths from ischemic heart disease

decreased 20 percent overall for the U.S.

population but only 13 percent for blacks. 

Minority children and chronically ill elderly

minority men and women may be especially

vulnerable to many of the inequities that lead to

disparities, and they may be unable to adequately

safeguard their own health and advocate for

themselves. Some recent AHRQ efforts in this area

include:

• In FY 1999, AHRQ announced funding of

$8.84 million over 3 years for 12 new research

projects to develop measures of quality of care

for vulnerable populations, such as people with

low literacy and high-risk infants. 

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Quality Research for Quality Health Care
• In FY 2000, AHRQ earmarked nearly 

$8 million to support projects that address the

goals of the President’s Initiative to Eliminate

Racial and Ethnic Disparities in Health. 

• AHRQ funded nine projects under the

EXCEED (Excellence Centers to Eliminate

Ethnic/Racial Disparities) initiative. These

projects address the factors that contribute to

ethnic and racial inequities in health care and

identify practical tools and strategies to

eliminate the disparities. 

Minority Health. AHRQ and its predecessor

agencies have been involved in research on

minority health issues for more than three decades.

For example, in the mid-1990s, AHRQ funded 11

MEDTEP (Medical Treatment Effectiveness

Program) Research Centers on Minority

Populations throughout the Nation. The

MEDTEP centers are concentrating on ways to

improve medical diagnosis and treatment and

disseminate information to help both minority

patients and their health care providers. In FY

1999 alone, AHRQ funded 49 grants with a major

emphasis on minority health. These grants have a

total value of more than $16.8 million.

AHRQ’s investments in minority health services

research have resulted in numerous findings that

are helping to shed light on the disparities

experienced by racial and ethnic minorities and

expand what is known about the reasons for those

disparities. AHRQ’s activities in FY 1999-2000 in

this area include:

• A study by researchers at Georgetown

University Medical Center to examine the

influence of race and sex on physicians’

recommendations for cardiac catheterization.

They found that black women are less likely

than white or black men or white women to be

referred for this procedure, which is considered

to be the “gold standard” test for diagnosing

coronary artery disease. The study involved 720

primary care physicians and eight patient actors

(two each white men, white women, black

men, and black women).

• A project to develop methods for risk

adjustment for surgical procedures that are

performed in otherwise healthy individuals.

The project focuses on hysterectomy, which is

performed at very high rates in black women,

who also have higher complication rates

compared with other women.

• A project that involves focus groups for Chinese

and Vietnamese patients to identify health care

issues that are important to them and develop

and validate patient questionnaires that are

sensitive to language and cultural barriers.

• A project to compare translated and nontranslated brochures (developed originally in

Spanish) currently being distributed to Spanishspeaking adults in southern Arizona and

Northern Mexico. The goal of the project is to

develop guidelines for preparing effective

written health-related materials in Spanish.

Women’s Health. In FY 1999, AHRQ met the

critical challenge of obtaining input from a broad

community of researchers, clinicians, policymakers,

consumers/patients, and advocates to identify

priorities for women’s health services research. As a

result, the Agency developed a new women’s health

initiative that broadened the program beyond

existing research on problems unique to women,

such as breast cancer, to fund studies that examine

the differences in patterns of care between men and

women. 

Domestic violence affects millions of women

and their families each year. It is the second leading

cause of injuries and death among women of

childbearing age. Women from all racial and ethnic

groups and income levels are victims of domestic

violence, and the consequences are seen in a range

of medical, obstetric, gynecologic, and mental

health problems. Direct health care costs associated

with domestic violence are estimated to be $1.8

billion per year. 

In FY 1999, AHRQ was approached by a

number of advocacy organizations and the Federal

Steering Committee on Violence Against Women

for assistance in developing a research-based

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performance standard for health care providers in

the area of domestic violence. AHRQ and other

HHS agencies worked together to convene a

meeting of experts to develop a health services

research agenda to address the health aspects of

domestic violence. 

In FY 2000, AHRQ invested $1 million in

research to evaluate health system responses to

domestic violence. These longitudinal studies are

the first of their kind and will move us beyond

studying prevalence, screening, and training to take

a rigorous look at health care interventions for

domestic violence and their effectiveness. Women

will be evaluated over time to identify interventions

that improve the health and safety of victims,

predict and improve health care use, prevent and

reduce the occurrence of domestic violence, and

develop better techniques to identify women at risk

for domestic violence. 

Examples of recent AHRQ-supported research

on women’s health issues include:

• A study of hysterectomy in women enrolled in

nine managed care organizations in Southern

California, which found that about 70 percent

of the hysterectomies performed on 497

women in these MCOs between 1993 and

1995 were inappropriate. These cases did not

meet the level of care recommended by an

expert panel or the criteria for hysterectomy

developed by the American College of

Obstetricians and Gynecologists. The most

common indications for hysterectomy were

benign tumors, pelvic relaxation, and bleeding.

The most common reasons for tagging

hysterectomy recommendations as

inappropriate were inadequate diagnostic

evaluation and failure to try alternative

treatments before hysterectomy.

• A study by researchers at Johns Hopkins

University, which found that physician

compassion can substantially reduce anxiety in

women who are newly diagnosed with breast

cancer. The study involved 123 healthy breast

cancer survivors and 87 women who had not

had cancer. Half of the women in each group

saw a standard videotape of two treatment

options for metastatic cancer. The other women

saw an enhanced compassion videotape in

which the doctor acknowledged the patient’s

concerns, touched her hand, and generally

expressed compassion and support. Anxiety

scores were significantly lower among women

in the second group.

• A study to examine the use of unplanned

cesearean delivery. Nearly 1 million c-sections

are performed in the United States each year,

and just over one-fourth of them are done for

lack of progress in labor. A recent study by

researchers at RAND, Brown University, and

UCLA found that each year thousands of these

cesareans done for lack of progress in labor may

be performed too early. The researchers note

that doctors may be more at ease with risks

associated with performing a c-section than

they are with continuing to observe a labor that

is not progressing as rapidly as expected. Or, the

doctors may disagree with recommendations

developed by ACOG or interpret them

differently. This study involved more than 730

women who delivered full-term, nonbreech

infants by unplanned c-section in Los Angeles

County and Iowa between March 1993 and

February 1994.

• White women are more likely than minority

women to receive hormone replacement

therapy (HRT), according to this study by

researchers at the University of California, San

Francisco. The study involved nearly 9,000

women, aged 50 and older, who were seen as

outpatients and prescribed HRT. White women

were significantly more likely to be given HRT

(33 percent) than Asians (21 percent), blacks

(25 percent), or Hispanics (23 percent). These

findings are particularly troubling for black

women who have coronary mortality rates that

are more than 30 percent higher than rates

among white women.

Children’s Health. Improving outcomes,

quality, and access to health care for America’s 70

million children and adolescents is a critical goal of

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Quality Research for Quality Health Care
health services research and central to the mission

of AHRQ. Understanding what’s needed to

improve health care delivery for children and

adolescents requires a special research focus.

Because children are growing and developing,

their health care needs and resource use differ from

adults. Unlike adults, they usually are dependent

on others for access to care and determinations

about the quality of care they receive. Several

AHRQ-funded studies on children’s health have

shown the importance of experience in caring for

children. 

AHRQ’s work in this area helps to fill the

major gap that exists in evidence-based information

on the health care needs of children and

adolescents. Such information is essential to

appropriately guide clinical and policymaking

decisions. The need for this information has

become particularly critical since the

implementation of the State Child Health

Insurance Program (SCHIP). In addition to the

RFAs funded by AHRQ in FY 1999—

Development of Quality of Care Measures for

Vulnerable Populations and Health Care Access,

Quality, and Insurance for Low-Income Children—

other research conducted and sponsored by the

Agency is contributing to the evidence base for

children’s health care decisionmaking. 

To address the paucity of quality measures for

children, AHRQ is supporting the development,

testing, and implementation of the Pediatric

Quality of Life measures. Also, AHRQ’s CAHPS®

children’s survey was adopted by the National

Committee for Quality Assurance for HEDIS—

the first time a health-plan-oriented survey of

children was administered nationwide. 

In FY 1999-2000, the Agency funded more

than 60 projects focused on children’s health issues.

Examples of findings from recent AHRQsupported research on children’s health include:

• Researchers from the University of Alabama at

Birmingham found that high-risk infants who

are born in hospitals with level-III neonatal

intensive care units (NICUs) are 38 percent less

likely to die than similar infants born in other

hospitals. Level-III NICUs treat a high volume

of such infants and thus have more experience

in their care. This study examined the effects on

neonatal mortality of NICU volume and the

level of NICU care available at the hospital of

birth for more than 50,000 infants born in

California in 1990. 

• Researchers from Johns Hopkins University

found better outcomes for children undergoing

dialysis when they were treated in facilities

experienced in providing this specialized

treatment for children. The study involved

more than 1,250 children undergoing

treatment at outpatient dialysis centers across

the country. 

• Referrals to specialists are uncommon among

pediatricians, according to the largest study ever

conducted of pediatricians’ referral patterns.

The study involved office visits to 142

pediatricians in 94 practices across 36 States.

The pediatricians in this study referred only 

1 of every 40 patients seen during office visits.

Unexpectedly, the researchers found that

gatekeeping arrangements nearly doubled the

odds of referral. 

• More than one-third of U.S. children from

both urban and rural communities lacked the

immunizations recommended for their ages in

the early 1990s, according to this study from

the University of Colorado. Low income, low

family education, minority race, parental

unemployment, and female sex were associated

with under-immunization. This was true even

in States that purchased and distributed

vaccines for all children to reduce cost and

improve access to immunization.

Medical Expenditure Panel Survey

AHRQ’s Medical Expenditure Panel Survey

(MEPS) provides highly detailed information on

how Americans use and pay for health care. This

ongoing survey of about 10,000 households each

year provides estimates for the country as a whole

and for important priority populations. One of the

principal products of the survey is a rich, research

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database that can be used by researchers at AHRQ

and elsewhere to examine a wide range of questions

on access to health care, cost and use of health care,

and insurance coverage. During FY 2000,

supplements and innovations to the data collection

expanded MEPS to include the collection of

information on health status and health care

quality.

Databases. MEPS produces a number of

analytical databases and, consistent with privacy

policy, releases a number databases to the public.

These databases include demographic, health care

use, access, expense, and insurance coverage

information for all survey participants. Additional

files detailing conditions, the specific content of

health care events, and employment of household

respondents also are made available to the public. 

Printed data. In addition to providing

databases for research use, AHRQ publishes MEPS

data in tabular form on a range of topics. Each

year, AHRQ releases hundreds of tables on the

health insurance coverage offered by employers.

These tables are derived from the MEPS Insurance

Component. The data are available for the Nation

as a whole, for important economic sectors, and for

many States. The MEPS staff also produce

findings, summaries/highlights, and methodology

reports. Chartbooks, which translate statistical

information into graphic form, expand access to

information from this important database. In 

FY 1999, the MEPS staff published a book that

discusses methodological and policy issues related

to two decades worth of AHRQ-sponsored medical

expenditure surveys.

Web site. To maximize the use of this

important investment, AHRQ has developed a

Web site specific to the MEPS. This Web site

rapidly disseminates databases and other products

to the research community and quickly responds to

inquiries from MEPS data users. By the end of FY

2000, AHRQ was responding to more than 100

inquiries made through the Web site each month.

We anticipate high growth, and future plans

include the development of sophisticated, online

tools so customers without statistical programming

skills can produce tabular data. Go to the Web site,

www.meps.ahrq.gov to review these exciting

features.

Training. To develop a cadre of sophisticated

MEPS users outside of AHRQ, the Agency has

developed a series of workshops, which range in

length from a few hours to several days. They

provide orientation to the policymaker and

researcher about the range of questions that MEPS

can answer and how the data can be properly used.

The longer workshops, which are geared to the

trained health services researcher, provide a “hands

on component” during which participants actually

have the opportunity to begin constructing their

own research file with technical assistance from

AHRQ staff. 

Data Center. The Center for Cost and

Financing Studies operates a Data Center through

which researchers and others with approved

projects can be allowed access to data that do not

meet standards for public release. Researchers with

approved projects are given access to those data

elements required to complete their projects, and

micro-data files are not released. Summary data are

released subject to review and approval by AHRQ

staff to ensure data confidentiality.

Healthcare Cost and Utilization Project

Scientifically sound, standardized databases at

the national, regional, and State levels and tools for

using them are needed to inform decisionmaking.

The Healthcare Cost and Utilization Project is

designed to fill this niche. HCUP is a FederalState-industry partnership to build a standardized,

multi-State health data system and companion set

of complementary resources. HCUP databases are

a family of longitudinal, administrative databases

including State-specific hospital-discharge

databases, State-specific ambulatory surgery

databases, and a national sample of discharges from

community hospitals. AHRQ maintains HCUP

and has taken the lead in making the databases

publicly available and in developing Web-based

products and software tools. 

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Quality Research for Quality Health Care
HCUP databases serve a unique function and

are being tapped by analysts and researchers

interested in hospital use, access, charges, quality,

and outcomes. Researchers rely on HCUP data to

identify, track, analyze, and compare trends at the

national, regional, and State levels. Because of their

large size, the HCUP databases are used to describe

patterns of care for both rare and common

diseases, analyze infrequent and frequent hospital

procedures, and track use for population

subgroups, such as minorities, children, women,

and the uninsured.

HCUP databases contain a core set of clinical

and nonclinical information on all patients,

regardless of payer— including those covered by

Medicare, Medicaid, or private insurance and the

uninsured—translated into a uniform format to

facilitate multi-State and National-State

comparisons and analyses. HCUP data include

over 100 variables, such as principal and secondary

diagnoses and procedures, admission and discharge

status, patient demographics, expected payment

source, total charges, length of stay, hospital

characteristics, and hospital and county identifiers

that permit linkages to other databases.

HCUP data users must agree to certain

conditions: the database can be used only for

research, analysis, and statistical reporting; attempts

to identify individuals are prohibited; and

institutions cannot be identified, either directly or

indirectly, in publications and other materials.

State Inpatient Databases (SID). Individual

data sets from 22 participating States make up the

1997 SID. Each data set contains the universe of

that State’s non-Federal hospital discharge abstracts.

All together, the SID represent about 60 percent of

all U.S. hospital discharges, totaling over 21

million inpatient discharge abstracts. State

participation is growing; the 1999 SID will include

26 states. The SID are particularly well-suited for

policy inquiries unique to a specific State, studies

comparing two or more States, market area

research, and small area variation analyses.

Currently, data are available for 

1995-1997.

State Ambulatory Surgery Databases

(SASD). The SASD include data sets from nine

States. As of FY 2000, 1997 data were available;

1999 data will be released in fiscal year 2001. The

SASD capture data on surgeries performed on the

same day in which patients are admitted and

released from hospital-affiliated ambulatory surgery

sites. Some SASD contain records from

freestanding surgery centers as well. 

The SASD are well suited for research that

requires complete enumeration of hospital-based

ambulatory surgeries within market areas or States.

Analysts and researchers use the SASD to compare

inpatient and outpatient ambulatory surgery

patterns, conduct market area research or small

area variation analyses, or identify State-specific

trends in ambulatory surgery use, access, charges,

and outcomes. 

Nationwide Inpatient Sample (NIS). The NIS

is a stratified probability sample of hospitals drawn

from the SID. The NIS is designed to approximate

a 20-percent sample of U.S. community hospitals.

Currently, the NIS includes 1988-1997 data. The

1997 NIS provides information on about 7 million

inpatient discharges from about 1,000 hospitals. It

is the largest all-payer inpatient database in the

United States. The NIS is ideal for research that

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State Inpatient Databases (SID)

Twenty-two States participate in the SID:

Arizona* Massachusetts*

California* Missouri

Colorado* New Jersey*

Connecticut New York*

Florida* Oregon*

Georgia Pennsylvania

Hawaii South Carolina*

Illinois Tennessee

Iowa* Utah* 

Kansas Washington*

Maryland* Wisconsin*

In FY 1999, AHRQ developed a designated

central distributor in which 14 States (*)

participate to facilitate access to their databases.
requires a large sample size and for developing

national estimates, analyzing national trends, and

providing benchmark statistics that can be

compared with regional and State statistics.

Web-based HCUPnet. HCUPnet is an

interactive, Web-based service developed by

AHRQ in FY 1999 for Federal and State

policymakers, health plan executives, and others

who need to identify, analyze, and compare

hospital inpatient statistics at the national, regional,

and State levels. HCUPnet provides inpatient data

from the Nationwide Inpatient Sample and, as of

FY 2000, 10 individual HCUP State Inpatient

Databases (SID). HCUPnet’s menu-driven format

permits users to tailor their online queries about

inpatient hospital care. Currently, 1997 data are

available. Most questions can be answered in 5

seconds or less. 

Users can request information related to specific

conditions, disease groups, or procedures, such as

length of stay, total charges, discharge status,

and/or in-hospital deaths. HCUPnet users can

refine their queries by selecting categories, such as

patient insurance status, age, sex, or hospital

characteristics (e.g., teaching status or type of

ownership). Go to the AHRQ Web site at

www.ahrq.gov to access HCUPnet free of charge.

HCUP Publications. In FY 1999, data from

HCUP were used to produce Hospital Inpatient

Statistics, a report detailing key characteristics

about hospital admissions. For example, the most

common reasons for hospital admission in the

United States are births (3.8 million admissions),

followed by coronary atherosclerosis (1.4 million

admissions), pneumonia (1.2 million admissions),

congestive heart failure (990,000 admissions) and

heart attack (774,000 admissions). 

HIV Data Coordinating Center. Swift

changes in treatment regimens resulting from

continuous therapeutic advances are having a

profound effect on resource use by people with

HIV infection. Because change is happening so

fast, data that were collected as recently as 3 years

ago do not reflect the current situation and cannot

be used reliably for policy and planning purposes. 

A new data coordinating center (DCC)

supported by AHRQ and the Office of the

Assistant Secretary for Policy and Evaluation

(ASPE), the Substance Abuse and Mental Health

Services Administration (SAMHSA), and the

Health Resources and Services Administration

(HRSA) collects current information about a large

number of individuals who have HIV disease from

providers who specialize in HIV care. The goal is

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Quality Research for Quality Health Care

State Ambulatory Surgery Databases

(SASD)

Nine States participate in the SASD:

Colorado*

Connecticut

Florida*

Maryland*

New Jersey*

New York*

South Carolina

Utah*

Wisconsin

Six States (*) participate in AHRQ’s

designated central distributor to facilitate access

to their databases.

HCUP Fact Books and Research Notes

• Hospitalization in the United States, 1997,

HCUP Fact Book No. 1, gives a snapshot of

hospital care in U.S. community hospitals

in 1997.

• Hospital Inpatient Statistics, 1996, provides

hospital stay data by principal diagnosis and

procedure.

• Most Common Diagnoses and Procedures in

U.S. Community Hospitals, 1996, provides

length-of-stay, charge, and mortality

statistics by diagnosis and procedure.

These publications are available from the

AHRQ Clearinghouse; call 800-358-9295.
to build a set of associated, publicly available

databases about the characteristics of patients and

the care they receive. Databases will not include

any patient or provider identifiers. The DCC

produces real-time information about access, costs,

and quality of care.

In FY 1999, AHRQ joined with ASPE,

SAMHSA, and HRSA to develop a pilot HIV data

center at the Johns Hopkins School of Medicine.

The data center tested on a small scale the

feasibility of transmitting data from HIV

caregivers. These included data on patient

characteristics, payer data, clinical data, and data

on the number of visits and admissions. In FY

2000, the pilot test was deemed successful. Efforts

were expanded to collect data from 20 to 30

providers who treat at least 20,000 people with

HIV disease.

The DCC provides an ongoing means to

collect timely information on resource use in HIV

disease. It is a cost-effective way to obtain

reasonably compete medical and financial

information on a large number of HIV-infected

patients, thus facilitating research on HIV care

among different types of patients.

Markets and Managed Care Research

AHRQ has taken the lead in supporting and

conducting research on health care markets and

changing organizational structures. The Agency

also has been a leader in developing and

maintaining databases and tools that enable

decisionmakers to understand how changes in

market dynamics or delivery system variables are

likely to affect outcomes, quality, access, cost, and

use of health care. Following are some examples of

recent AHRQ-supported research on markets and

managed care.

• A 1999 study by researchers at Georgetown

University looked at whether HMO

penetration affects physician earnings. They

found that HMOs did reduce physicians’

annual and per hour earnings in 1990,

presumably through a combination of fewer

visits and lower payment rates for people

covered by HMOs. According to the

researchers, these results may be somewhat

conservative because they reflect market

behavior prior to the rapid growth and more

aggressive market behavior of HMOs in recent

years.

• A 1997 study examined the effects of

physicians’ personal financial incentives and

other measure of involvement with HMOs on

three measures of satisfaction and practice style:

overall practice satisfaction, the extent to which

prior expectations about professional autonomy

and the ability to practice good-quality

medicine are met, and several specific measures

of practice style. The researchers conducted a

telephone survey of more than 1,500

physicians. About 15 percent of respondents

reported a moderate or strong incentive to

reduce services; 70 percent reported a neutral

incentive; and 15 percent reported an incentive

to increase services. Compared with physicians

who had a neutral incentive, physicians with an

incentive to reduce services were 1.5 to 3.5

times more likely to be very dissatisfied with

their practices. The researchers concluded that

although financial incentives to reduce services

are not widespread, there is a legitimate reason

to be concerned about possible adverse effects

on the quality of care. 

• In recent years, most health care markets in the

United States have experienced rapid

penetration by HMOs and preferred provider

organizations (PPOs). During the same period,

growth in health care costs has slowed. The

researchers used a national database to examine

the relationship between price competition and

hospital cost growth in the early 1990s. They

found that between 1989 and 1994, HMOs

and PPOs significantly restrained cost growth

among hospitals located in competitive hospital

markets. This did not hold true, however, for

hospitals located in relatively concentrated

markets. The researchers concluded that HMOs

have contained cost growth more effectively

than PPOs.

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• An analysis of data from a 1993 survey of

nearly 1,500 hospitals revealed that the

relationship between managed care and

physician and clinical integration is relatively

modest. The goal was to empirically estimate

the effects that managed care has on physician

and clinical integration in urban hospitals.

Other things being equal, physician

involvement in hospital management and

governance increase with managed care

involvement. To a lesser degree, the use of

physician organization arrangements and other

similar ventures also increase. In this study,

practice management and support services were

lower in hospitals with high managed care

activity. Larger hospitals, investor-owned,

system, and nonteaching hospitals had larger

managed care revenues, while revenues from

managed care were lower in more concentrated

hospital markets.

• Two trends—managed care and physicianhospital integration—have been prominent in

reshaping insurance and provider markets over

the last decade. An assessment of the impact of

HMO market structure on the formation of

physician-hospital strategic alliances in the mid1990s suggests that hospitals form alliances

with physicians for several reasons. Alliances

serve to contract with the growing number of

HMOs, they pose a countervailing bargaining

force of providers in the face of HMO

consolidation, and they accompany hospital

downsizing and restructuring efforts.

• AHRQ research has shown that Medicaid

managed care enrollment is progressing more

slowly in rural areas of the country, while

growing rapidly in the rest of the country.

Medicaid enrollees in only slightly more than

half of the rural counties in the United States

were covered by some type of managed care in

early 1997, compared with nearly three-fourths

of those in urban counties. Also, there are

important differences in rural and urban areas

in the types of managed care programs.

According to this study, mandatory fully

capitated programs are less common in rural

counties than in urban ones (10 percent versus

23 percent), although seven States do have

State-wide mandatory fully capitated Medicaid

programs. And finally, programs that combine

different types of managed care are less

common in rural counties.

User Liaison Program

AHRQ’s User Liaison Program (ULP)

synthesizes and distributes research findings to

local, State, and Federal policymakers so they can

use it to make evidence-based decisions about

health care. ULP holds small workshops to provide

information to policymakers on the critical issues

confronting them in today’s changing health care

marketplace. These workshops are user-driven and

user-designed. ULP solicits input from legislators,

executive agency staff, and local officials on policy

issues where they need information and technical

assistance. 

In FY 1999, ULP held 17 workshops attended

by 843 health care policymakers from 48 States,

the District of Columbia, Puerto Rico, Virgin

Islands, Micro Polynesian Islands, and Guam.

Twelve of these were national workshops attended

by policymakers from around the country, and five

workshops were held for specific audiences. ULP

held another 17 workshops in FY 2000 that

provided training for 635 attendees from 50 States

and the District of Columbia.

Future Directions 

AHRQ’s FY 2001 budget of $269.9 million

will allow us to expand the Agency’s investment in

health services research to devote more attention to

developing the much-needed evidence-based

information that will provide the foundation for

health care decisions well into the new century. In

addition, the reauthorization legislation passed in

FY 2000 affirmed the Agency’s core mission and

gave us a new charge to improve the quality of

health care services provided in the Nation. 

31

Quality Research for Quality Health Care
We will do this by building on the foundation

already laid by AHRQ for promoting evidencebased practice, stepping up research on medical

errors and other patient safety issues, translating

research into tools and strategies to improve the

quality of health care services, and developing the

information needed to answer questions about

access to health care and its cost and use. 

As this report goes to press, we have already

begun to address these new challenges. For

example, much of AHRQ’s increased focus on

patient safety and medical errors will be

concentrated in the Agency’s Center for Quality

Measurement and Improvement. To more

appropriately reflect this expanded mission, the

Center has been renamed as the Center for Quality

Improvement and Patient Safety. Congress has

instructed AHRQ to devote $50 million in FY

2001 to find ways to improve patient safety. We

have been instructed to:

1. Establish a competitive demonstration program

for health care facilities and organizations to

test best practices for reducing errors.

2. Determine ways to improve provider training in

order to reduce errors.

3. Develop guidelines on the collection of uniform

data related to patient safety.

Congress designated $10 million of AHRQ’s

FY 2001 budget for research on the relationship

between the health care workplace and its impact

on medical errors and the quality of care provided

to patients. AHRQ’s Center for Primary Care

Research will coordinate agency-sponsored research

in this area. Potential research topics include the

impact of extended work hours for registered

nurses on patient safety, the effects of restructuring

the health care workplace to reduce costs on the

health of workers and the quality of their lives, the

assignment of work to health care workers (e.g.,

new approaches to work shifts and working hours),

and improvements in health care working

conditions that could be undertaken by employers

to improve patient safety. 

FY 1999 and FY 2000 were very productive

years for the agency. We will continue our

investment in health services research, which will

provide the evidence-based information and tools

needed to enhance health care decisionmaking in

years to come. We expect that the end result of

AHRQ’s research will be quantifiable

improvements in health care in America that will

be measured in improved quality of life and patient

outcomes, deaths averted, and dollars saved.

32

www.ahrq.gov
http://www.ahrq.gov/

Don’t Forget—

Visit AHRQ’s Web Site

AHRQ’s

Web site

—http://www.ahrq.gov/—

makes practical, science-based

health care information available

in one convenient location. You

can tap into the latest

information about the Agency

and its research findings and

other initiatives, including

funding opportunities and job

vacancies. Research Activities is

also available and can be

downloaded from our Web site.

Do you have comments or

suggestions about the site? Send

them to info@ahrq.gov.
Department of Health and Human Services

Agency for Healthcare Research and Quality

www.ahrq.gov

March 2001

AHRQ Publication No. 01-0018